Who do citizens hold responsible for outcomes and experiences? Hundreds of rural hospitals have closed or significantly reduced their capacity since just 2010, leaving much of the rural U.S. without access to emergency health care. I use data on rural hospital closures from 2008 to 2020 to explore where and why hospital closures occurred as well as who–if anyone–rural voters held responsible for local closures. Despite closures being over twice as likely to occur in the Republican-controlled states that did not expand Medicaid, closures were associated with reduced support for federal Democrats and the Affordable Care Act following local closures. I show that rural voters who lost hospitals were roughly 5–10 percentage points more likely to vote Republican in subsequent presidential elections. If anything state Republicans seemed to benefit in rural areas from rejecting Medicaid and resulting rural health woes following the passage of the ACA. These results have important implications for population health and political accountability in the U.S.